Angle between shaft and neck should be 120-130º
Femoral Head
Femoral Neck
Intertrochanteric
Trochanteric, either greater or lesser
Subtrochanteric
Femoral Shaft-needs traction to reduce pain, swelling, elongate bone
Legg-Calve-Perthes
Avascular necrosis of femoral head seen in 5-7 y/os
Slipped Capital Femoral Epiphysis (SCFE)
10-16 y/o, obese, m>f
C/o knee discomfort, especially with sports
AP Bilat hips c frogs view
Hip will be externally rotated
Septic Arthritis
Hip will be flexed, abducted, and externally rotated
Temp>38.3, pain in hip is increased c gentle motion
Diagnosis is assured if rapid response to antibiotics
Bursitis
This patient sustained a Morel-Lavalle lesion. The
Morel-Lavalle lesion is a closed internal degloving injury that is recognized
clinically as significant soft-tissue ecchymosis, typically in the region of the
greater trochanter. It is seen in association with pelvic trauma and is
frequently associated with acetabular fractures. A cavity of hematoma and
liquefied fat is produced from a shear injury in which the subcutaneous tissue
is torn away from the underlying fascia. These injuries have been reported to
result in serious infection in over 45% of patients (1).
The clinical significance of this injury may not be initially apparent: its
clinical appearance may not convey the serious soft tissue injury that is
indicated by the lesion and it may be overlooked as attention is focused on bony
injuries.
As noted, there is a high incidence of bacterial colonization in closed
degloving injuries associated with severe pelvic trauma. The Morel-Lavalle
lesion should be treated by thorough debridement prior to or at the time of the
pelvic or acetabular surgery. (Emedhome.com)
Must be reduced
known as a hip pointer. Consider abd trauma. A 5-8 day course of burst steroids may reduce disability.
Complications: hip fx, vascular trauma, peroneal nerve, quad muscle damage
3 in 1 femoral nerve block for fractured neck of femur (Annals EM 41:2, 2003)
PELVIS and HIP
The pelvis and hip are radiographically complex structures, and fractures in
these areas comprised a substantial portion of malpractice claims as studied by
ACEP in 1974-1985. Overlapping bones and the oblique orientation of many
structures on the AP view are often the cause of radiographic
misinterpretations. The normal anatomy of the pelvis and hip are depicted in
Figure 13.
Figure 13. AP radiograph and diagram of the pelvis
Hip “D”islocations can be classified as anterior and posterior. Posterior
hip dislocations are more common and are often caused by a dashboard intrusion
injury against the knees in motor vehicle crashes. On physical exam, patients
with posterior dislocations lie with their affected leg shortened and internally
rotated. Conversely, patients with anterior dislocations lie with their
affected leg shortened and externally rotated. Radiographically, the femoral
head no longer approximates with the acetabular fossa (Figure 14). In the event
of an unsuccessful hip reduction, computed tomography (CT) imaging is
recommended to evaluate for obstructive intra-articular bone fragments. Often,
hip dislocations are also associated with femoral head and acetabular fractures.
Figure 14. Left hip posterior dislocation
(AP view)
There are three extremely important “O”ccult fractures of the pelvis and hip
which require careful scrutiny. The first is a femoral neck fracture (Figure
15)-- the most commonly missed hip fracture. Occurring primarily in the elderly
and osteoporotic population after a fall directly onto the hip, femoral neck
fractures can be extremely subtle on plain radiographs. Approximately 2-9% of
hip fractures are, in fact, radiographically normal (15,16). Underappreciated
findings include cortical discontinuity, hyperlucency along the line of
impaction, interruption of the smooth cortical transition from femoral neck to
femoral head, and trabecular disruption. A study by Parker demonstrated that 16
of 825 hip fractures were initially overlooked. Because of the delayed
diagnosis, 15 of the 16 missed fractures, which were initially nondisplaced,
were displaced upon re-presentation (17). Because of this significant
complication of overlooking a femoral neck fracture, MRI has become the
recommended imaging modality of choice in the ED for a patient with a high
suspicion for a femoral neck fracture, despite normal plain radiographs of the
hip. The sensitivity and specificity of an MRI in detecting such fractures is
100% (18). As a less sensitive and less specific alternative, CT imaging may be
used instead with the risk of missing fractures that are oriented in the axial
plane.
Figure 15. Right femoral neck fracture (AP view)
The second “O”ccult fracture is of the sacrum. One study demonstrated that
72% of sacral fractures were missed initially (19). When radiographically
examining the pelvis, be sure to look specifically at the sacrum. Detection of
a subtle break in the smooth alar lines suggests a sacral fracture as seen in
Figure 16. Upon visualizing a sacral fracture, subsequent CT imaging is often
necessary to evaluate the extent of the sacral fracture because neurological
deficits such as cauda equina and radiculopathy occur 22% of the time (20), and
associated pelvic fractures are frequently overlooked on plain radiographs.
When neurological deficits are present, sacral fractures often undergo surgical
repair. Consultation with an orthopedist or neurosurgeon is necessary for all
sacral fractures because of these significant co-morbidities (21).
Figure 16. Right-sided sacral fractures (AP view)
And the third “O”ccult fracture involves the acetabulum, the pelvic
articulation site for the femoral head. The acetabulum can be divided into
anterior and posterior columns. The disruption of the iliopubic line suggests
an anterior acetabular fracture as seen in Figure 17, and a disruption of the
ilioischial line suggests a posterior acetabular fracture. Additionally, when
looking for a posterior acetabular fracture, one must carefully examine the
portion of the acetabulum behind the superimposed femoral head. Using this
approach, a subtle posterior acetabular fracture can also be visualized in
Figure 17.
Figure 17. Right anterior and posterior acetabular fractures (AP view)
Pelvic and hip fractures often occur in multiples because the pelvis
structurally resembles a closed ring. By the law of physics, a fracture through
one part of a ring will expectedly cause a fracture through another part of the
ring. Thus, the diagnosis of an isolated fracture of the pelvis may only
represent “H”alf of the injuries present. Special attention must be paid to the
aforementioned fractures in addition to subtle rami fractures, sacroiliac
dissociation, and L5 transverse process fractures as potential additional sites
for pelvic ring disruption
RCT showing it is effective in the ED (Annals of Emergency Medicine 2003;41(2):227)
A 22G, 50 mm short bevel insulated needle attached to nerve stimulator (0.6 mA) is inserted adjacent to the lateral border of the femoral artery (FA) at the level of inguinal crease, (IC; a skin fold 3 to 6 cm below and parallel to the inguinal ligament), Figure 2 and Figure 4. The needle is slowly advanced at an angle of 60° cephalad to the horizontal plane while seeking a quadericeps muscle twitch. If a quadericeps muscle twitch is not obtained within a depth of 50 mm, the needle is withdrawn and redirected 10° laterally. If this maneuver does not elicit a quadericeps muscle twitch, the subsequent needle insertions should be placed at increments of 5 mm lateral to the previous insertion sites. Once a quadericeps muscle twitch is obtained at <0.4 mA, the local anesthetic (30 ml of 1.5% Mepivacaine with 1mEq of HCO3 and 1:300,000 epinephrine) is injected.
However, when the initial response is a sartorius muscle twitch, the quadriceps muscle twitch is sought by incrementally re-directing the needle laterally 10° at a time, and increasing the penetration depth to 10 mm. The onset of blockade is typically within 3-5 minutes when the current is < 4.0 mA and it os documented by loss of sensation in the anterior thigh and saphenous nerve distribution, as well as the presence of quadriceps muscle relaxation.
In patients still suspected of having a hip fracture after initial negative radiographs, 4.4% had hip fracture on MRI (Acad Emerg Med 2005;12(4):366)
MRI is the gold standard for dx
Trochanteric fxs do not need treatment
femoral neck fxs are at risk for AVN
Clinical scenario
A 77 year old woman presents to the emergency department following a simple fall
in which she has sustained a fractured neck of femur. You have recently
completed a secondment in anaesthetics and consider a "3-in-1" block for pain
relief. One of the consultants with whom you worked stated that to perform a
nerve block without using a nerve stimulator would be poor clinical practice.
When you gave the example of nerve blocks in fractured neck of femur he
commented that ultrasound has been used as an alternative to nerve stimulators
in this setting.
Search strategy
Medline using Ovid interface 1966–March 2006, CinAHL using Ovid interface 1982
to March Week 2 2006 and Cochrane: via NELH 2006 Issue 1. "femoral and
ultrasound and anaesthesia". Medline: {[(Exp. Ultrasonography or ultrasound$.mp
or sonographic guidance.mp) or (electrical nerve stimulator$.mp or electrical
nerve stimulation.mp)] and (exp. Nerve block$ or femoral nerve block$.mp or
3-in-1 block.mp or three in one block$.mp or three-in-one block$.mp or triple
block.mp or lateral cutaneous nerve block$.mp or obturator nerve block$.mp)}
(limited to human, English and abstracts in Medline but not in CinAHL).
Cochrane: "femoral and ultrasound and anaesthesia".
Search outcome
137 papers were found through Medline, of which two were relevant to the three
part question (see table 2). No additional papers were found in CinAHL or the
Cochrane Librayry.
View this table:
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Table 2
Cochrane: 21 citations found but no new papers.
Comment(s)
Conformation of needle placement in regional anaesthesia is seen by many as a
vital part of the procedure. Many anaesthetists would argue that to perform such
procedures without a nerve stimulator is not best practice, and has implications
within clinical governance. In the emergency department the use of a nerve
stimulator for three-in-one blocks would result in muscular contraction that
would cause increase pain and risk fracture displacement. Although the trials
are small, the data presented would suggest that ultrasound guide three-in-one
block may be an alternative to nerve stimulation in the emergency department.
CLINICAL BOTTOM LINE
Ultrasound guidance is better than electrical nerve stimulation at obtaining a
good quality three in one femoral block.
References
Marhofer P, Schrogendorfer K, Koinig H. Ultrasonographic guidance improves
sensory block and onset time of three-in-one blocks. Anaesthesia and Analgesia
1997 Oct;85(4):854–7.
Marhofer P, Schrodendorfer K, Wallner T, et al. Ultrasonographic guidance
reduces the amount of local anaesthetic for 3-in-1 blocks. Regional Anaesthesia
and Pain Medicine 1998 Nov-Dec;23(6):584–8.
